Synopsis
Plan oncological oesophagectomy or gastrectomy around tumour site, margins, lymphadenectomy, conduit and reconstruction, while preventing pulmonary, anastomotic and nutritional harm.
- Ivor Lewis oesophagectomy uses abdominal and right-thoracic phases with an intrathoracic anastomosis; McKeown adds a cervical phase and places the anastomosis in the neck. Tumour level, nodal field, prior therapy, physiology and specialist expertise determine the choice.
- The gastric conduit is usually perfused through the right gastroepiploic arcade; identifying and protecting that pedicle and checking the tube for viability are explicit reconstruction steps.
- Subtotal gastrectomy preserves function when a clear proximal margin is oncologically achievable; total gastrectomy is required for diffuse, proximal or extensive disease.
Key red flags
Persistent postoperative tachycardia is an early leak warning and must not be attributed automatically to pain or atelectasis.
A pale, congested or poorly perfused gastric conduit threatens necrosis and anastomotic failure and requires immediate senior review.
Tachycardia, fever, sepsis, neck discharge or enteric chest drainage can precede obvious radiological contrast leak.
Reasoning priorities
Estimate whether radical resection and recovery are realistic.
Integrate performance status, frailty, pulmonary function and exercise capacity rather than using chronological age alone.
Worked reasoning
A fit 57-year-old completes preoperative chemotherapy for a distal gastric adenocarcinoma; restaging and laparoscopy show no metastasis and the proximal stomach is endoscopically clear.
- The specialist oesophago-gastric surgical unit reviews restaging, nutritional reserve and tumour position and selects subtotal rather than total gastrectomy because an adequate proximal margin is achievable.
- The specialist team performs subtotal gastrectomy with D2 lymph-node dissection and Roux-en-Y reconstruction, preserving the proximal reservoir without compromising the planned nodal field.
- Final pathology reports an R0 resection with a clear proximal margin and complete node count, so the postoperative oncology discussion uses the pathological response rather than the preoperative scan alone.
- Verify functional recovery as well as cancer clearance: before discharge the patient tolerates six small oral intakes, mobilises independently and has a documented dietetic, B12/haematinic and oncology follow-up plan.